General Surgery Coding Alert

Although the AMA and CPT state that you shouldnt use 38792 and 78195 during the same session, following that advice could be costing your firm valid reimbursement. In part one of this two-part series on sentinel node biopsies, we discuss the proper method to report the imaging portion of these multistep procedures.

The sentinel node is the first lymph node to receive drainage from a cancer-containing area of the breast (or other area of the body). Sentinel lymph node biopsy involves identification, removal and evaluation of lymph nodes that drain the area of a malignant tumor. The surgeon may use either of two methods, or a combination of both, to identify a sentinel node, says Donna J. Richmond, RCC, CPC, of Acadiana Computer Systems Inc., a billing, practice management software and services and consulting company based in Lafayette, La.:

1. Direct visualization (38792, Injection procedure; for identification of sentinel node): The surgeon injects the vital dye (such as isosulfan blue) shortly before surgery to stain the lymphatic vessels that drain the tumor site, thereby allowing him or her to identify the sentinel node.

2. Lymphoscintigraphy (78195, Lymphatics and lymph nodes imaging): This nuclear medicine procedure involves injecting a radioisotope, such as technetium-99, under the skin several hours prior to surgery. The isotope acts as a radioactive "tracer," which can be mapped by a gamma camera as it flows into the sentinel node and its lymphatic channel. Most often, a radiologist will perform this procedure, although a surgeon may on rare occasions perform and bill for it.

Although 38792 and 78195 describe distinct procedures, the AMAs CPTAssistant (Dec. 1999: Vol. 9, Issue 12) instructs, "The injection of radioactive tracer is included in the lymphoscintigraphy procedure [78195] performed at the same session and is not reported separately. Therefore, it is inappropriate to report 38792 when lympho-scintigraphy is performed." This blanket statement suggests that 38792 is inappropriate even if direct visualization requires a separate injection (in other words, if the surgeon injects vital dye in addition to a radioactive tracer, you still may not report 38792 separately).

CPT Assistant goes on to state, "In some cases, the physician will only perform the injection of the radioactive tracer, after which the patient will be sent for same-day sentinel node biopsy procedure with node identification performed using the operative handheld gamma detector. In this instance, nuclear medicine imaging lymphoscintigraphy is not performed. When identification through injection of a radioactive tracer of a sentinel node(s) is performed without scintigraphy imaging, report code 38792."

In other words, according to AMA/CPT guidelines, says Cindy Parman, CPC, a radiology coding and reimbursement specialist, member of the American Academy of Professional Codersnational advisory board and president of Coding Strategies Inc. in Dallas, Ga., you would not report both 38792 and 78195 for the same patient during the same session: 78195 always includes 38792.

Note that individual payers, including Medicare, may allow separate reimbursement for 38792 and 78195, regardless of AMAs instructions. Empire Medicare Services, the local Part B Carrier for New York, for instance, specifies in its draft local medical review policy (LMRP), dated Feb. 13, 2002, "When lymphoscintigraphy is performed in advance of the surgical procedure to locate and mark the sentinel node(s), the injection and the lymphoscintigraphy procedures should be coded and reported separately by the physician performing these procedures. CPT code 38792 should be used for the injection procedure, and code 78195 should be used for the lymphoscintigraphy" [emphasis added].

Further, the same LMRPspecifies, "The injection of vital dye to visualize the sentinel node in the operating room should be reported by the surgeon/physician who performs the injection using code 38792 When both a radioactive tracer and vital dye are used, reimbursement of CPTcode 38792 will be made for both the injection of the radioactive tracer and the injection of the vital dye" [emphasis added]. In other words, the surgeon may report 38792 twice: once for injection of the isotope and once for injection of the dye for direct visualization. (But even if the surgeon makes four separate injections of dye, you may report only a single unit of 38792.)

"Typically for breast sentinel node biopsy, we inject both dye and radioisotope," says M. Trayser Dunaway, MD, FACS, a general surgeon in private practice in Camden, S.C. "It makes actually finding the node easier."

For example, if the surgeon injects a radioactive isotope for lymphoscintigraphy and also injects vital dye for further, direct visualization, you may report 78195 (for the scintigraphy) and 38792 x 2 (once for injection of the isotope and once for injection of the dye). But if a radiologist, rather than the surgeon, performs the isotope and scintigraphy, the surgeon may not bill these procedures as well.

Because you do not wish to forfeit legitimate reimbursement, always be sure to check your payers policies prior to billing these procedures. Automatically following CPTs suggested guidelines in this case can lead to lost revenue.